ATI RN
Complication Postpartum Questions
Question 1 of 5
The nurse is caring for a postpartum client who experienced a second-degree perineal laceration at delivery 2 hours ago. Which of the following interventions should the nurse perform at this time?
Correct Answer: A
Rationale: The correct answer is A) Apply an ice pack to the perineum. This intervention is appropriate for a second-degree perineal laceration as it helps to reduce swelling, inflammation, and pain in the perineal area. The application of ice packs also promotes vasoconstriction, which can help in minimizing bleeding and promoting healing of the laceration. Option B) Advise the woman to use a sitz bath after every voiding is not the most appropriate intervention at this time because using a sitz bath may not be recommended immediately after delivery, especially in the case of a recent perineal laceration. Sitz baths are generally recommended after the initial postpartum period when the perineal area has started to heal. Option C) Advise the woman to sit on a pillow may provide some comfort but does not directly address the issue of managing the perineal laceration or promoting healing. Option D) Teach the woman to insert nothing into her rectum is a general postpartum instruction to prevent infection but does not specifically address the immediate care needed for a second-degree perineal laceration. In an educational context, it is essential for nurses to understand the appropriate interventions for postpartum complications like perineal lacerations to provide optimal care and promote the well-being of their patients. Proper knowledge and application of evidence-based practices in postpartum care can help prevent complications and support the healing process for new mothers.
Question 2 of 5
A postoperative cesarean section woman is to receive morphine 4 mg q 3 -4 h subcutaneously for pain. The morphine is available on the unit in premeasured syringes 10 mg/1 mL. Each time the nurse administers the medication, how many milliliters (mL) of morphine will be wasted? Calculate to the nearest tenth.
Correct Answer: B
Rationale: The correct answer is B) 0.6 mL. To calculate the wastage, we first determine the total morphine used in 24 hours, which is 4 mg every 3-4 hours. If we assume the maximum frequency (every 3 hours), the patient would receive 6 doses in 24 hours (24 hours ÷ 3 hours = 8 doses, but the last dose is not fully utilized). Therefore, the total morphine used in 24 hours is 24 mg (4 mg/dose x 6 doses). Given that each syringe contains 10 mg/1 mL, the total volume of morphine needed in 24 hours is 2.4 mL (24 mg ÷ 10 mg/mL = 2.4 mL). However, since the syringes are premeasured and contain 1 mL each, there will be a wastage of 0.4 mL per dose. Therefore, for 6 doses in 24 hours, the total wastage will be 2.4 mL (0.4 mL/dose x 6 doses), which is equivalent to 0.6 mL when rounded to the nearest tenth. Educationally, understanding medication calculations is crucial for safe and effective nursing practice. Nurses must be able to accurately calculate dosages to prevent medication errors and ensure patient safety. This question highlights the importance of precise calculations in medication administration to minimize wastage and optimize patient care.
Question 3 of 5
A client is receiving an epidural infusion of a narcotic for pain relief after a cesarean section. The nurse would report to the anesthesiologist if which of the following were assessed?
Correct Answer: A
Rationale: In this scenario, the correct answer is option A) Respiratory rate 8 rpm. This is the most critical assessment finding that would require immediate reporting to the anesthesiologist. The administration of a narcotic via epidural infusion can lead to respiratory depression as a side effect, especially when higher doses are used. A respiratory rate of 8 rpm is dangerously low and could indicate impending respiratory failure, a potentially life-threatening complication that requires immediate intervention. Complaint of thirst (option B) is a common side effect of narcotic medications but is not as urgent or concerning as respiratory depression. Urinary output of 250 mL/hr (option C) is within normal limits and not directly related to the administration of a narcotic. Numbness of feet and ankles (option D) is a common side effect of epidural anesthesia and does not indicate a critical issue requiring immediate attention. Educationally, this question highlights the importance of monitoring patients receiving epidural narcotic infusions postpartum for potential complications, particularly respiratory depression. Nurses must be vigilant in assessing vital signs and responding promptly to any signs of respiratory distress to ensure patient safety.
Question 4 of 5
A post -cesarean section, breastfeeding client, whose subjective pain level is 2/5, requests her as needed (prn) narcotic analgesics every 3 hours. She states, 'I have decided to make sure that I feel as little pain from this experience as possible. ' Which of the following should the nurse conclude in relation to this woman 's behavior?
Correct Answer: C
Rationale: The correct answer is C) The woman's breast milk volume may drop while taking the medicine. This is the correct answer because narcotic analgesics can pass into breast milk and affect the infant. Opioids, like narcotics, can lead to decreased milk production and potentially drowsiness or breathing difficulties in the newborn. It is essential for the nurse to educate the mother about the potential risks associated with taking narcotics while breastfeeding. Option A is incorrect because increasing the strength of the narcotic is not necessary and may increase the risk of adverse effects for both the mother and the baby. Option B is incorrect because while constipation is a potential side effect of narcotic analgesics, it is not the most immediate concern in this scenario. Option D is incorrect because while newborns can experience withdrawal symptoms if the mother is taking narcotics consistently, the primary concern in this situation is the potential impact on breastfeeding due to the medication. Educationally, it is vital for healthcare professionals to understand the implications of prescribing medications to breastfeeding mothers and to provide thorough patient education to ensure the safety and well-being of both the mother and the newborn.
Question 5 of 5
The nurse is assessing the midline episiotomy on a postpartum client. Which of the following findings should the nurse expect to see?
Correct Answer: B
Rationale: In assessing a midline episiotomy on a postpartum client, the nurse should expect to see well-approximated edges (Option B). This indicates proper healing and closure of the incision site. Well-approximated edges suggest that the incision is healing as expected and reduces the risk of infection and other complications. Option A, moderate serosanguinous drainage, may be expected in the immediate postpartum period, but it is not a specific finding related to the assessment of the episiotomy incision site. Option C, an ecchymotic area distal to the episiotomy, suggests bruising, which is not a typical finding in a well-healing incision. Option D, an area of redness adjacent to the incision, could indicate inflammation or infection, which would be concerning and not expected in a healing episiotomy. Educationally, understanding the expected findings in assessing a postpartum episiotomy is crucial for nurses to provide appropriate care, monitor for complications, and intervene promptly if needed to promote optimal healing and recovery for postpartum clients.